American Surgical Association
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A New Era in the Surgical Treatment of Atrial Fibrillation: The Impact of Ablation Technology and Lesion Set on Procedural Efficacy
Spencer J. Melby, MD*, Andreas Zierer, MD*, Rochus K. Voeller, MD*, Shelly Lall, MD*, Marci S. Bailey, RN*, Marc R. Moon, MD*, Ralph J. Damiano, Jr., MD
Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, MO, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO

OBJECTIVE: While the Cox-Maze procedure (CMP) remains the gold standard for the surgical treatment of atrial fibrillation (AF), the use of ablation technology has revolutionized the field. In order to simplify the procedure, our group has replaced most of the incisions with bipolar radiofrequency (BPRF) ablation. The purpose of this study was to examine results using BPRF in 130 patients undergoing either a full CMP, a limited CMP (LCMP), or pulmonary vein isolation (PVI) alone.
METHODS: A retrospective review was performed of patients who underwent a CMP (n=100), utilizing BPRF ablation, a LCMP (n=7), or PVI alone (n=23, Table 1). Followup was available on 129 of 130 patients (99%).
RESULTS: PVI was confirmed by intraoperative pacing in all patients. Cross-clamp time in the lone CMP patients was 44±21 minutes, while it was 104±42 minutes for the CMP with a concomitant procedure, which was shortened considerably from our traditional cut-and-sew CMP times (p<0.05). There were four postoperative deaths in the CMP group, one in the PVI group, and none in the LCMP group. The mean follow-up was 33±25, 23±25, 57±37 months for the CMP, LCMP, and PVI groups, respectively. At last follow-up freedom from AF was 89% (84/94), 86% (6/7), and 53% (10/19) in the in the CMP group, LCMP group, and PVI alone group, respectively.
CONCLUSIONS: The use of bipolar radiofrequency ablation to replace Cox-Maze incisions was safe and effective at controlling AF. PVI alone was much less effective, and should be used cautiously in this population.
Patient Characteristics and Procedures Performed
CMP (n=100)PVI (n=23)LCMP (n=7)
Male gender (%)57 (57%)15 (65%)5 (71%)
Age (years)62 ± 1362 ± 1451 ± 16
Persistent AF (%)41 (41%)11 (48%)5 (71%)
Mean AF duration (months)78 ± 93 (1-480)92 ± 154(1-600)158 ± 183 (15-492)
Left atrial diameter (cm)5.8 ± 1.35.5 ± 1.4 (n=16)5.1 ± 0.9 (n=6)
Left ventricular ejection fraction48 ± 1343 ± 1151 ± 14
NYHA III-IV (%)59 (59%)17 (74%)5 (71%)
Freedom from AF at last follow-up89% (84/94)53% (10/19)86% (6/7)
Anti-arrhythmics at last follow-up31% (29/93)12% (2/17)43% (3/7)


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